Minding Our Zeros and Ones: Are Psychiatrists Ready for Neurotechnology?

One small sip for “S3” was one miraculous leap for neurotechnology. According to a recent report in Nature, a 58-year-old woman with long-standing tetraplegia (named “S3” in the report) mobilized a free-standing robotic arm to reach out and grasp a cup of coffee-a highly complex fine-motor movement-with merely her thoughts.¹

Five years before this awe-inspiring moment, a tiny neural implant (called BrainGate) with 96 electrodes was implanted in S3’s motor cortex. BrainGate’s sensor recorded the electrical activity of an array of motor neurons triggered when S3 imagined specific reach and grasp movements; these patterns of motor signals were “translated” (digitalized) into a series of zeros and ones that instructed a computer to operate an independent robotic (mechanical) arm with 3-dimensional movements. With a neural-computer interface, S3 could grasp a cup of cof-fee with brain signals alone. Remarkably, the motor cortex’s firing pattern-the sequence of zeros and ones-that had been recorded 5 years earlier remained essentially unchanged. S3 had a brain-computer interface to thank for restoring volitional movements to her paralyzed limb. Such an achievement is just one of many notable stories unfolding in the emerging field of neurotechnology.

Neurotechnology refers to the science of applying our emerging understanding of the brain, consciousness, thought, and higher-order activities of the mind into developing technologies. The tools of neurotechnology, however, are not new for psychiatrists. For example, in the realm of diagnostic imaging, functional MRI (fMRI) scanning discoveries have linked the brain’s anatomy with localized emotional and cognitive functions and dysfunctions.

One groundbreaking finding was Area 25 that Helen S. Mayberg, MD, identified as a “nerve center” for depression; it may be a reliable barometer for antidepressant treatment as well.² Moreover, modern electro- and magneto-encephalography can detect tumors, find stroke sites, and specify epilepsy-prone brain areas. Other advances in neuroimaging promise to identify dysfunctional neural circuits associated with human psycho­pathology and suffering.

Beyond diagnostics, neurotechnologies are used in psychiatric treatment. The electromagnetic “wand” used in repetitive transcranial magnetic stimulation (rTMS) is FDA-approved for the treatment of depression, and emerging research indicates that rTMS could help less-en the intrusive thoughts of obsessive-compulsive disorder, improve the painful apathy associated with certain psychotic disorders, and diminish chronic pain caused by migraine headaches and phantom limb syndrome.

Neural implants, including computer chips and optic probes, are already in use to treat epilepsy and Parkinson disease. Similarly, research is under way to use deep brain stimulators to treat obsessive-compulsive disorder, refractory depression, Tourette syndrome, and addictions and to curb appetite and reduce obesity. Advanced drug delivery systems are being designed to zero in on diseased brain sites or turn on genes that could promote cell growth-and to do so without the degree of collateral damage associated with less precise methods.

Smart drugs, “nootropics,” that selectively boost the functioning of neural circuits involved in memory and cognition are another budding frontier. Perhaps the most incredible application is the field of optogenetics, where specially engineered, light-activated (or light-inactivated) ion channels are implanted in the brain to curtain the firing of neurons associated with anxiety or trauma. Native to unicellular algae found in a pond, these implantable ion channels-such as blue-light–activated channelrhodopsin that promotes neuronal firing or yellow-light–activated halorhodopsin that actually silences a neuron-can now assist neuroscientists in disentangling complicated neural circuits and, perhaps, in identifying an anxiety gene that could be targeted with gene therapy. This work is under way with mice, a few cortical steps away from man.³

Neurotech’s brainchildren have also attracted considerable non-medical attention. Advancing from science fiction to applied science is a fast-growing, $8 billion business, with investments from commercial, military, and academic interests. While neurotechnologies may be poised to produce magic bullets for clinical medicine, the military hopes they might also fire live ammunition. (Just as S3 can reach for a cup of java with her thoughts, a soldier could similarly operate weaponries with brain-computer interfaces.)

Marketers, too, dream of a neurotechnology that could read minds to then specifically mer-chandize their hosts. And there are many mere human egos eager to have turbocharged brains that function far beyond our all-too-ordinary selves. Yet with every scientific step forward, there is also the prospect of intended and unintended missteps-of applications that are a step in space where no one should go.

The prospect of mismanaging the power of neurotechnology has spawned the field of neuroethics, bringing us face-to-face with questions about who will have access to these culture- (and ethos-) changing technologies, and to what ends they will be utilized. Psychiatrists, neurologists, and neuroscientists, therefore, will have to confront questions of how to best apply novel neurotechnologies in an equitable and ethical way. For example, consider some of the following thornier neuroethical issues.

First, who should benefit? Memory-enhancing treatments, for example, usher in a host of questions about their applications. We may be on firm moral ground when it comes to offering cognitive-enhancing medications or other neurotechnologies to restore lost brain functions to individuals with Alzheimer disease, debilitating cerebro­vascular accidents, multiple sclerosis, and other prevalent and disabling brain diseases. So, too, is the imperative to treat victims of traumatic brain injury who will need medicines or procedures to modulate or erase the traumatic memories that can sear into the brain after a disaster, in combat or from torture or abuse, leaving them “invisibly” yet severely wounded. These inter­ventions make sense.

But should doctors prescribe cognitive enhancers to boost the functioning of a healthy brain or implant artificial neurons or stem cells to fur-ther the mental performance of those healthy from the start? Should recipients be those with debilitating illnesses-or should corporate CEOs and mediocre students (those who can afford it) attain supercharged brains?

What about the use of neurotechnology in homeland security or the corporate marketplace? Will consumers be able to ask their doctor for a nootropic or will it be available on amazon.com? Will (“when” is more likely) a black market emerge? What will be the FDA’s role in dif-ferentiating snake oil from the next truly magic pill or device? Neuroethicists will have plenty to consider.

Moreover, what principles should guide the allocation of precious and powerful resources and services in a society? Should the market forces of supply and demand determine who will get what is needed (or desired) and who will not? Ethicists, policymakers, and clinicians are familiar with these questions of “distributive justice” in which health care resources are meant to be distributed to maximize wellness and minimize misfortune. Meant is a goal, but the question remains as to how.

Second, what should be the psychiatrist’s role in the applications of neurotechnology? Will mental health clinicians have access to fine-tuned diagnostics and new treatments of brain illnesses? Will these new technologies themselves open further windows into heretofore mysteries of the brain? How will our field be changed? How will the profession set its standards and shape its practices?

Beyond everyday clinical practice, neurotechnology may assess a defendant’s veracity or provide forensic evidence for an insanity defense. But while emerging technologies seek to reduce error, applying science in the courtroom is rife with legal ambiguities. Cutting-edge DNA fingerprinting (or DNA typing) provides a contempo-rary example: while scientists and lawyers agree on the uniqueness of an individual’s DNA typing, how the legal system can best apply this datum to assigning innocence or guilt continues to bewilder judges. Debates already rage as to whether fMRI lie-detection scans or EEG-based brain fingerprints are rigorous enough to meet standards of scientific evidence. The jury is still out.

The frontier extends to your mind being read at the local shopping center. Product “neuromarketing” corporate consumer psychoanalysis, if you will, has advertisers using functional brain scanning to assess a buyer’s unconscious reactions to the latest widget that would then allow advertisers to fashion a subliminal pitch that closes the sale by clinching your mind. How will brain research translate into the global marketplace? What about nonmedical institutions, such as government, law enforcement, or academic institutions, using mind-reading devices to make security determinations? The opportunities, and intrusions, are legion.

Third, how will we maintain our medical and mental privacy? If neurotechnologies can figure out how the mind works, read our brain’s thoughts, and even predict our intentions, will privacy be a thing of the past? New standards of medical privacy will need to be written-and regulated. But, by whom?

As of this writing, S3’s sipping coffee remains a remarkable achievement of clinical neurotechnology. Progress is science’s “most important product.” And neurotechnology’s products will yield colossal benefits-making it seductive to dismiss risks for the sake of benefits. There is nothing new here: we have always had to weigh risk against benefit. We want to savor S3’s sip-and the myriad marvels of neurotechnology-but we also need to grasp its risks and carefully govern its advances. There is no technology to guide the way, alas, only our humanity and values.

References:

References

1. Hochberg LR, Bacher D, Jarosiewicz B, et al. Reach and grasp by people with tetraplegia using a neurally controlled robotic arm. Nature. 2012;485:372-375.

2. Mayberg HS, Lozano AM, Voon V, et al. Deep brain stimulation for treatment-resistant depression. Neuron. 2005;45:651-660.

3. Schoonover CE, Rabinowitz A. Control desk for the neural switchboard. New York Times. May 16, 2011. http://www.nytimes.com/2011/05/17/science/17optics.html?pagewanted=all&_r=0. Accessed October 4, 2012.